Nursing Informatics Teaching Toolkit: Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula

Transcription

1 Nursing Informatics Teaching Toolkit: Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula

2 Production of this document was supported by the Canada Health Infoway Clinicians in Training program. Published by: Canadian Association of Schools of Nursing Association canadienne des écoles de sciences infirmières 99 Fifth Avenue, Suite 15 Ottawa ON K1S5T3 Canadian Association of Schools of Nursing, Nursing Informatics Teaching Toolkit

3 Nursing Informatics Teaching Toolkit: Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula

4 Acknowledgements The Canadian Association of Schools of Nursing (CASN) gratefully acknowledges Ella Mann, RN, MSc for developing this resource. CASN acknowledges the expertise, time, and contributions of the Generating Momentum to Prepare Nursing Graduates for the Electronic World of Health Care Delivery project Task Force: Noreen Frisch (Chair), RN, PhD, FAAN Professor and Director, School of Nursing, University of Victoria Irma Jean Bajnok, RN, PhD Director, International Affairs and Best Practice Guidelines Centre Co-Director, Nursing Best Practice Research Unit, Registered Nurses Association of Ontario Cynthia Baker, RN, PhD Executive Director, Canadian Association of Schools of Nursing Sandra Bassendowski, RN, EdD Professor, College of Nursing, University of Saskatchewan Elizabeth Borycki, RN, PhD Associate Professor, School of Health Information Science, University of Victoria Denise Bowen, RN, MN Chair, School of Health and Human Services, Aurora College Maureen M. Charlebois, CHE, MHSc, BScN RN Clinical Adoption, Chief Nursing Executive & Group Director Lorie Donelle, RN, PhD Assistant Professor, Arthur Labatt Family School of Nursing, Western University Kathryn Hannah, RN, PhD Hannah Education and Consulting Services Inc. Health Informatics Advisor, Canadian Nurses Association Professor (Adjunct), School of Nursing, University of Victoria Professor (Adjunct), Department of Biomedical Informatics, Published by: University of Utah Alexandra Harris, RN, MN/MHSc Canadian Association PhD of Student Schools & of Research Nursing Officer, University of Toronto Association canadienne des écoles de sciences infirmières Sylvie Jetté, RN, PhD 99 Fifth Avenue, Professor, Suite School 15 of Nursing, University of Sherbrooke Margot McNamee, RN, MHA Ottawa Senior ON K1S5T3 Nurse Advisor, Member Engagement, Canadian Nurses Association Lynn Nagle, RN, PhD President, Nagle & Associates Inc. Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Catherine Peirce, MA Project Manager, e-learning, The Association of Faculties of Medicine of Canada Patricia Seaman, RN, PhD Assistant Dean UNB/Humber Collaboration Faculty of Nursing, University of New Brunswick Loretta Secco, RN, PhD Faculty of Nursing, University of New Brunswick Tracy Shaben, RN, MN Canadian Nursing Informatics Association Representative / Lead, Clinical Informatics, University of Alberta Hospitals sites, Alberta Health Services Anna Sherlock, RN, MBA Clinical Leader, Clinical Adoption, Canada Health Infoway Anne Tran Fazzalari, M.E.S National Project Manager, Clinical Adoption, Canada Health Infoway 4 Nursing Informatics Teaching Toolkit

5 Table of Contentss Preamble Section 1: Introduction to the Nursing Informatics Teaching Toolkit Toolkit Organization and Use Introduction Background and Rationale General Nursing Informatics Resources Section 2: Information and Knowledge Management Information and Knowledge Management Competency and Indicators Context Key Concepts Key Learnings Gathering, Assessing and Using Information and Knowledge for Evidence-Informed Nursing Assisting Patients/Clients in Using Information and Communication Technologies in Managing Their Health Nursing Data and the Advancement of Nursing Practice The Current State of Standardized Clinical Terminologies International Classification for Nursing Practice (ICNP) Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) Canadian Health Outcomes for Better Information and Care (C-HOBIC) Other Standardized Nursing Terminologies Applying the Standardized Clinical Terminologies and Collecting Standardized Data in Nursing Canadian Health Outcomes for Better Information and Care (C-HOBIC) Project The Registered Nurses Association of Ontario (RNAO) Best Practice Guideline Nursing Order Sets SNOMED CT and pan-canadian EHRs Benefits of Standardized Clinical Terminologies to Nursing Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 5

6 2.4 Information and Knowledge Management Case Study Presentation on Information and Knowledge Management Resources Related to the Information and Knowledge Management Competency Section 3: Professional and Regulatory Accountability Professional and regulatory accountability competencies and indicators Context Key concepts: Key Learnings: Awareness of Legislation and Policies that Regulate the Use of ICT in Nursing Practice Federal and Provincial Health Privacy Policies and Standards Nursing Health Privacy Policies and Standards Organizational Policies Information and Communication Technologies and Patient Safety Information and Communication Technologies and the Nurse s Clinical Judgement Nurses as Advocates for Health Information and Communication Technologies Professional and Regulatory Accountability Case Study Presentation on Professional and Regulatory Accountability Resources Related to the Professional and Regulatory Accountability Competency Section 4: Use of Information and Communication Technologies Use of Information and Communication Technologies competencies and indicators Context Key Concepts Key Learnings The Introduction of Electronic Health Records in Canada Point-of-care Systems Functionality Interoperability Nursing Informatics Teaching Toolkit

7 4.3.1 Nursing and Electronic Health Records Comparing the Electronic Health Records, Electronic Medical Records, and Personal Health Records Electronic Health Records (EHRs) Electronic Medical Records (EMRs) and Other Point-of-Care Systems Personal Health Records (PHRs) Optimizing the Delivery of Patient Care Harnessing Information and Communication Technologies for the Delivery of Care Improved Documentation Decision Support at the Point-of-Care Preventing Gaps in Patient Care Improvements to Inter-professional Patient Care Ensuring that Information and Communication Technologies Support the Nurse-Patient Relationship Use of Information and Communication Technologies Case Study Presentation on the Use of Information and Communication Technologies Resources Related to the Use of Information and Communication Technologies Competency Section 5: Glossary of Terms Section 6: References Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 7

8 Preamble In 2011, the Canadian Association of Schools of Nursing (CASN) embarked on a mission to engage nursing faculty, students, and other key stakeholders in developing nursing informatics outcome objectives for undergraduate nursing curricula, and in building capacity among Canadian nurse educators to teach nursing informatics. The project was funded by Canada Health Infoway, a not-for-profit organization formed in 2001 to promote the transformation of healthcare through health information technology by developing a blueprint for electronic health records, fostering the adoption of electronic records for all Canadians, creating standards for technology and communication, and promoting clinician facility with health information technology. For an informatics transformation of health care to take root, new nurses and other health professionals entering the workforce must be prepared to use health information and communication technology in practice. To this end, Infoway created the Clinicians-in-Training Initiative, to support the preparation of future nurses who graduate and enter the workforce with the ability to practice in modern, technology-enabled clinical environments. As a first step, CASN created Nursing Informatics Entry-to-Practice Competencies for Registered Nurses. Three national consensus based competencies and indicators were developed using an extensive consultation process involving key stakeholders across Canada. The competencies detail the core nursing informatics knowledge and skills that nursing students should possess upon completion of a baccalaureate nursing program in Canada. In order to assist faculty to integrate the competencies into undergraduate curricula, CASN conducted an environmental scan of nursing informatics resources to develop a Nursing Informatics Inventory of Existing Teaching and Learning Resources. Many gaps in resources, however, were evident. The Nursing Informatics Teaching Toolkit was created, therefore, to fill these gaps and augment the resources available to teach these competencies. The Nursing Informatics Teaching Toolkit serves two purposes. First, it provides key concepts and key learnings summarizing information faculty should know to teach each competency; secondly, it provides faculty with teaching tools that they can easily integrate into pre-existing lesson plans. For each competency there is a case study, a PowerPoint presentation, and discussion/quiz questions that can be used in the classroom. As CASN is a national organization of schools of nursing, the Nursing Informatics Teaching Toolkit was designed for use by nursing faculty. Many other individuals, however, may find this toolkit helpful, particularly faculty from other health science disciplines, nursing students, and practicing nurses. 8 Nursing Informatics Teaching Toolkit

9 Section 1: Introduction to the Nursing Informatics Teaching Toolkit Section 1: Introduction to the Nursing Informatics Teaching Toolkit 1.0 Toolkit Organization and Use This toolkit is organized according to the three CASN nursing informatics entry-to-practice competencies and their accompanying indicator set. The three entry-to-practice competencies are: y Uses relevant information and knowledge to support the delivery of evidence-informed patient/client care. y Uses information and communication technologies (ICTs) in accordance with professional and regulatory standards and workplace policies. y Uses ICTs in the delivery of patient/client care. There are four components under each competency: 1. Key Concepts This section defines key nursing informatics concepts that are components of the competency. Faculty should familiarize themselves with these concepts and include them in their teachings. 2. Key Learnings This section provides background information on the content of the competency. The purpose of the Key Learnings section is to increase faculty comfort in teaching topics related to the CASN competency. 3. Presentation Each presentation is a collection of slides that may be used and/or adapted as needed. Sample quiz or test questions are also included. The section starts with an overview of how the slides could be used, which slides could be removed to shorten the length of the presentation, and how they might be integrated into curricula. 4. Case Study and Discussion/Quiz Questions Each case study provides an example teaching strategy to support nursing informatics education. The case study is introduced with information on how it might be used, adapted, and integrated into a program. Sample quiz or discussion questions are included. Answers to the discussion/quiz questions are provided, along with references where faculty can find more information. Various resources with general information and teaching resources that faculty may find helpful are highlighted in the background section of each competency and can be identified by pictures as outlined below: General Resources: This section provides articles, books, relevant websites and/or other sources of information related to a given topic. Resources to Support Teaching: This section suggests articles, books, audio-visual tools and websites that that can facilitate teaching or provide insight on how to teach a particular topic. Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 9

10 Section 1: Introduction to the Nursing Informatics Teaching Toolkit 1.1 Introduction Scholes and Barber (1980) coined the term nursing informatics defining it as...the application of computer technology to all fields of nursing-- nursing services, nurse education, and nursing research (p 73). A more recent definition that reflects current nursing practice comes from the International Medical Informatics Association (2009). It states that nursing informatics is a science and practice [that] integrates nursing, its information and knowledge, and their management, with information and communication technologies to promote the health of people, families and communities worldwide. Informatics became a specialty in Canadian nursing in the early 1980s with the introduction of health information systems (HIS) into hospitals. Information technology specialists were unable to operate these systems without the assistance of nurses because some of their functions required clinical knowledge for order entry and results reporting. As a result, Nursing Systems Coordinators (NSC) emerged as a specialized position within hospitals. NSCs would work alongside IT specialists until the HIS was implemented, and nursing staff were properly trained to use it (NNIP, 1999). In recent years, as health information technologies become a routine part of the practice landscape in healthcare workplaces, there has been a recognition that all nurses need competencies in nursing informatics, and indeed, should enter the workforce prepared to use health information and communication systems (Bond, 2009). Nursing Practice Nursing Knowledge & Information Nursing Informatics Information & Communication Technologies While nursing students, as part of the millennial generation, may have more experience with the technological component of nursing informatics than faculty, they lack the knowledge and skills to use the technology in the provision of patient care. A survey of 42 graduating nurses found that they rated themselves as having minimal or moderate skills on 43 nursing informatics competencies (Fetter, 2009). A study of Canadian schools of nursing paints a picture that suggests a majority of nurse graduates have received little preparation in nursing informatics. Although two-thirds of schools indicated that informatics was included in the curriculum, they were unsure of the specific content, where it appeared in the program, and how many hours were devoted to it. Moreover, many respondents conveyed a common misconception that the use of teaching technologies, such as PowerPoint, Blackboard or WebCT, constitute nursing informatics (Nagle & Clarke, 2004). In 2012, CASN authored the Nursing Informatics Entry-to-Practice Competencies for Registered Nurses to provide Canadian nursing faculty with a resource that delineates the specific knowledge, skills, and attitudes in informatics that students will need to possess when they enter the workforce. The competencies that CASN identified are: 1) Uses relevant information and knowledge to support the delivery of evidence-informed patient/client care; 2) Uses information and communication technologies in accordance with professional and regulatory standards and workplace policies; and 3) Uses information and communication technologies in the delivery of patient/client care. 10 Nursing Informatics Teaching Toolkit

11 Section 1: Introduction to the Nursing Informatics Teaching Toolkit The Nursing Informatics Teaching Toolkit offers nursing faculty a second resource that supports faculty integration of the core nursing informatics competencies into curricula by providing background information on the competencies, as well as teaching and learning tools that educators can use in the classroom. 1.2 Background and Rationale The effects of technology in healthcare are wide reaching, and have the potential to improve access, efficiency, research, and the overall quality of care delivery. The World Health Organization recognized these benefits, and recommended that member states establish long-term strategies to develop and implement e-health services (WHO, 2005). Canada has forged a path with many strategies to improve healthcare through the use of information and communication technologies (Aglukkaq, 2013). A significant amount of money has been invested in Canada in developing and integrating electronic health records to attain greater efficiency in the current health system while maintaining or improving the quality of care. It is projected that their use will reduce health care costs over the long-term as cost-savings are expected to arise from a variety of resulting changes, including a reduction in paper and associated filing and storage, improved screening, earlier identification of health problems, and faster treatment (Ball et al., 2011; Marchildon & DiMatteo, 2011). The use of information and communication technologies (ICTs) also offers the potential of improving patient safety by reducing errors. The Canadian Patient Safety Institute has identified paper-based methods as a poor mechanism for tracking errors because of factors such as the frequent illegibility of hand-written information, lost time or information as forms are passed through appropriate people, and difficulties in achieving a standard sized form to match descriptions of variable length. ICTs offer more effective tools for recording, tracking, and analyzing rates of adverse events in order to prevent the recurrence of common errors (Ball, Douglas, & Hinton Walker, 2011; White, 2007). In addition to error reduction, ICTs can increase patient safety and improve patient outcomes by: 1) integrating evidenced-based recommendations and reminders/alerts into electronic records or clinical information systems (CIS) (Ball et al., 2011; Saba & McCormick, 2006); 2) improving the monitoring, screening, and early identification and treatment of disease (Ball et al., 2011); 3) supporting safer prescribing and administration of medications (Saba & McCormick, 2006); 4) facilitating communication between health care professionals, health settings, and geographic locations (Canada Health Infoway, 2012a; Canada Health Infoway, 2012b); and 5) engaging patients/clients in self-management (Canada Health Infoway, 2012b; Kupchunas, 2007). ICTs provide greater opportunities for healthcare delivery and patient engagement. Telehealth for example, is important in improving access to health services (e.g. for those living in rural areas). With guidance from health professionals, internet access allows patients and families to retrieve quality information and supports their participation and management of health. The multiple potential benefits of ICTs that have been identified depend on clinicians abilities to make use of them. Pre-licensure education of health professionals in informatics is, therefore, a key component in bringing the potential benefits to fruition. Thus, nursing students need to be equipped to embrace and use evolving systems, and are more likely to do so if they have the confidence that they have developed the necessary skills for this. Building selfefficacy in low-stress and familiar situations such as class assignments, labs, and/or clinical Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 11

12 Section 1: Introduction to the Nursing Informatics Teaching Toolkit simulation learning experiences can help prepare students to use health information and communication technologies in higher-stress and unfamiliar clinical settings (Ball et al., 2011). Additionally, by using ICTs when practicing other nursing skills (e.g. assessment), students can learn and practice skills related to the technologies within the patient care context, and see how the technologies may result in improved patient outcomes. For example, a student working with a computer, smartphone app, or tablet while assessing a pressure sore can be cued to look for clinical practice guidelines to further inform the assessment and decision-making process (Ball et al., 2011). Moreover, learning about informatics and using ICTs in practice situations allows students to relate the technologies to other key nursing concepts such as confidentiality, evidence-informed care, documentation, and inter-professional collaboration (Williamson, Fineout Overholt, Kent, & Hutchinson, 2011). In summary, the rationale for integrating nursing informatics into nursing curricula is multifaceted and has become an imperative for all undergraduate nursing programs. It is our hope that the materials, resources, and references provided in this toolkit will facilitate the learning of future nurses, and support the successful integration of core nursing informatics content into nursing education. 1.3 General Nursing Informatics Resources Below is a list of general health/nursing informatics sources of information: websites, nursing informatics journals, online e-health courses, and academic literature on nursing informatics in baccalaureate education. General Resources: Agency for Healthcare Research and Quality: y y Example use: access the health IT evaluation forms Canada Health Infoway: y y Example use: include available videos in lectures to help with teaching Canada s Health Informatics Association (COACH): y y Example use: read articles in their online journal related to health informatics Canadian Institute for Health Information (CIHI): y y Example use: search for articles on health information and communication technologies by Canadian health care professionals Centre for Health Evidence: y y Example use: search for resources on using clinical practice guidelines with health technologies Health Canada: y or y Example use: search for national initiatives and updates related to health informatics in Canada 12 Nursing Informatics Teaching Toolkit

13 Section 1: Introduction to the Nursing Informatics Teaching Toolkit Registered Nurses Association of Ontario (RNAO) ehealth Toolkit: y y Example use: access to better understand the strategies and best practices for successful implementation of ehealth into health facilities and nursing practice RNAO Nurse Educator ehealth Resource for the Integration of ehealth into Undergraduate Nursing Curricula: y y Example use: access as a practical guide to information about how and where to integrate ehealth knowledge and skills into entry level curricula using the CASN Competencies Canadian Nursing Informatics Association (CNIA): y y Example use: network with nurse informaticians and access information about nursing informatics events International Medical Informatics Association (IMIA) Nursing Informatics Group y y Example use: access information for students and faculty on international initiatives in nursing informatics International Council of Nurses International Classification of Nursing Practice: y y Example use: access detailed information on nursing data standards developments internationally Journals: Computers, Informatics, Nursing y International Journal of Nursing Terminologies and Classifications y International Journal of Medical Informatics y Free Online Courses offered by the Registered Nurses Association of Ontario (registration required): y Nurses and Mobile Technology o Available at: y ehealth for Every Nurse o Available at: Resources to Support Teaching: Ainsley, B. & Brown, A. (2009). The impact of informatics on nursing education: A review of the literature. Journal of Continuing Education in Nursing, 40(5), Brancato, V.C. (2006). An innovative clinical practicum to teach evidence-based practice. Nursing Educator, 31(5), De Gagne, J.C., Bisanar, W.A., Makowski, J.T., & Neumann, J.L. (2012). Integrating informatics into the BSN curriculum: A review of the literature. Nurse Education Today, 32(6), Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 13

14 Section 1: Introduction to the Nursing Informatics Teaching Toolkit Elder, B.L. & Koehn, M.L. (2009). Assessment tool for nursing student computer competencies. Nursing Education Perspectives, 30(3), Fetter, M.S. (2008). Enhancing baccalaureate nursing information technology outcomes: Faculty perspectives. International Journal of Nursing Education Scholarship 5, article 3. Weiner, E.E. (2008). Supporting the integration of technology into contemporary nursing education. Nursing Clinics of North America, 43(3), Williamson, K. M., Fineout Overholt, E., Kent, B., & Hutchinson, A. M. (2011). Teaching EBP: Integrating technology into academic curricula to facilitate evidence based decision making. Worldviews on Evidence-Based Nursing, 8(4), Nursing Informatics Teaching Toolkit

15 Section 2: Information and Knowledge Management Section 2: Information and Knowledge Management 2.0 Information and Knowledge Management Competency and Indicators Competency: Accesses and communicates relevant information and knowledge to support the delivery of evidence-informed patient/client care. Indicators: y Performs search and critical appraisal of on-line literature and resources (e.g., scholarly articles, websites, and other appropriate resources) to support clinical judgement, and evidence-informed decision making. y Analyses, interprets, and documents pertinent nursing data and patient data using standardized nursing and other clinical terminologies (e.g., ICNP, C-HOBIC, and SNOMED CT, etc.) to support clinical decision making and nursing practice improvements. y Assists patients and their families to access, review and evaluate information they retrieve using ICT (i.e. current, credible, and relevant) and with leveraging ICT to manage their health (e.g. social media sites, smart phone applications, online support groups, etc.). y Describes the processes of data gathering, recording and retrieval, in hybrid or homogenous health records (electronic or paper), and identifies informational risks, gaps, and inconsistencies across the healthcare system. y Articulates the significance of information standards (i.e. messaging standards and standardized clinical terminologies) necessary for interoperable electronic health records across the healthcare system. y Articulates the importance of standardized nursing data to reflect nursing practice, to advance nursing knowledge, and to contribute to the value and understanding of nursing. y Critically evaluates data and information from a variety of sources (including experts, clinical applications, databases, practice guidelines, relevant websites, etc.) to inform the delivery of nursing care. 2.1 Context Nurses acquire the competencies in undergraduate education that prepare them for nursing practice. A significant component of what they need to learn is the understanding that they must continually inform their actions with evidence (CNA, 2010). Information is easily accessed through the internet. Nurses must be prepared, however, with the skills to find high quality sources of data that may be used as evidence. Clients have the same widespread access to the internet and use it to research, share information, and find support in relation to their health. Clients also often require guidance in actively retrieving good quality health information to guide their health behaviours. Reliable, quality information can support patient/client participation in managing their health, whereas poor quality information can lead to negative patient/client outcomes such as buying unnecessary or harmful products, increased stress or fear, or delaying seeking care (Ball et al., 2011; Kupchunas, 2007). Universities and similar institutions have to make the necessary adjustments to harness new forms of transformative learning made possible by the IT revolution, moving beyond the traditional task of transmitting information to the more challenging role of developing the competencies to access, discriminate, analyse and use knowledge (The Lancet Commissions, 2010, p. 29). Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 15

16 Section 2: Information and Knowledge Management Advancements in technology have led to new ways of gathering, documenting, communicating, and retrieving data. Documenting nursing activities allows nurses and other health professionals to see the impact of nursing care on patient outcomes. Patient/client data can serve as evidence for nurses, other health professionals, and even policy makers. For example, the information and actions documented may provide data to determine the registered nurse to practical nurse ratio in a care facility (CNA, 2009). 2.2 Key Concepts Information Literacy Information literacy is the ability to seek out information when there is a need, find high quality sources, and apply them appropriately. Ball et al. (2011) identifies the following information literacy skills as essential for nurses: 1. Identifying an information need 2. Accessing information relevant to the need 3. Evaluating the information for quality and applicability 4. Applying the information to the need 5. Evaluating the outcomes Health Literacy Health literacy is the ability to access, understand, and act on information for health. Health professionals, such as nurses, play a key role in developing health literacy skills by providing clear and accurate information to clients (Health Literacy Council of Canada, 2011). Standardized Clinical Terminologies Standardized Clinical Terminologies are common languages that are used to describe health conditions (e.g. symptoms, diseases, etc.) as well as treatment plans and interventions. Electronic health information systems that use standardized clinical terminologies allow nurses and other health care professionals to exchange information readily as theycoordinate patient care within and across various practice settings. This document contains information on two standardized clinical terminologies that are relevant to the Canadian nursing context: y International Classification for Nursing Practice (ICNP) y Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) y Canadian Health Outcomes for Better Information and Care (C-HOBIC) y Other standardized nursing languages (SNLs) that may be used in specialty settings or that may be incorporated in vendor systems purchased for use in health care settings Standardized Nursing Data Standardized nursing data refers to a uniform collection of nursing data from the patient record, which may include nursing diagnosis, interventions, outcomes, and the intensity of nursing care (Anderson and Hannah, 1993). 16 Nursing Informatics Teaching Toolkit

17 Section 2: Information and Knowledge Management 2.3 Key Learnings Gathering, Assessing and Using Information and Knowledge for Evidence-Informed Nursing ICTs give health care providers timely access to relevant sources of evidence in clinical, research, and other settings. Nurses must be equipped with information literacy skills to ensure the information is appropriate, of high quality, and applicable to nursing activities. There are many different types of evidence that can be accessed using health communication technologies. Below is a five-level pyramid of sources of evidence for the delivery of evidence-informed care developed by Brian Haynes (Haynes, 2007). Haynes 5S Model Systems (e.g. Electronic health records) Summaries (e.g. Clinical practice guidelines) Synopses (e.g. Short descriptions of reviews or studies) Syntheses (e.g. Systematic review) Studies (e.g. Single study) Although online searches increase the quantity of information available to nurses, disadvantages include the potential lack of quality in websites and the time required to sort through the large volume (Ball et al., 2011). One means of retrieving high quality evidence is to use trustworthy websites such as Public Health Agency of Canada ( phac-aspc.gc.ca/index-eng.php), and the Canadian Nurses Association s Nurse One Portal ( Using the search portals on these websites helps ensure the quality of retrieved evidence. Similarly, databases can be used to access evidence sources in certain subject areas. An example database is the Cumulative Index of Nursing and Allied Health Literature (CINAHL), which contains over three million records organized by Medical Subject Headings (MeSH). When using a database to collect information, it is still important to evaluate the quality of the research. Hierarchies are available to help nurses assess the quality of evidence for both quantitative and qualitative studies. Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 17

18 Section 2: Information and Knowledge Management In the Haynes pyramid, single case studies appear at the lowest level (Haynes, 2007). Nurses may still need to use single case studies to inform them when they are presented with a unique situation. If the study is helpful to the unique situation, nurses should also consider whether applying the results is consistent with the agency s standards, whether the study s findings can be implemented (i.e. the health condition/demographic profile is similar to the patient s), the barriers to applying the study, and the strength of the research design. New opportunities exist for accessing clinical practice guidelines. For example, Registered Nurses Association of Ontario s BPGs are available in a condensed format for use on PDAs. Guidelines are available at: Evidence based practice recommendations are embodied in clinical practice guidelines available on websites such as the Registered Nurses Association of Ontario s Best Practice Guidelines (available at or Clinical Evidence (available at: clinicalevidence.org). Clinical practice guidelines, such as RNAO s, are strengthened by a rigorous development process (AGREE II, 2010) that involves a systematic review, and includes identification of the level of evidence for the recommendations according to a framework included in each guideline. Systems are at the highest level in Haynes 5S model due to the potential for a patient s/client s data to be linked with appropriate summaries (e.g. clinical practice guidelines) in an electronic system, such as an electronic health record. If guidelines are embedded into the electronic system, they can provide point-of-care information specific to the characteristics and context of the patient/client. Electronic health records and point-of-care information systems (e.g. hospital information systems or electronic medical records) are prime examples of systems that have the potential to provide clinical decision support at various levels of care (e.g. from the bedside, to the organization, to provincial/territorial and national levels). For example, computerized clinical decision support can be used to guide treatment and care of individual patients with diabetes, and can also be used as a tool to increase influenza vaccinations amongst a population residing in a specific health region. At other times, performing a general search using a search engine such as Google may be necessary. Nursing students have a tendency to use a general internet search instead of a more trustworthy source (Flynn, 2001). Students should be encouraged to assess the quality of websites by evaluating: y The source and its purpose o Example: a company trying to sell its products or an organization aiming to support individuals with a certain health condition y The credentials and potential bias of the author(s) o Example: a pharmacist working for a pharmaceutical company or an explicit statement addressing any conflict of interest for the author y Accurate and verified content o Example: the information should be consistent with other sources, and may reference other sources y Website and content maintained and updated with current information o Example: a recent last updated date at the bottom of the website 18 Nursing Informatics Teaching Toolkit

19 Section 2: Information and Knowledge Management y Clear references o Example: who is referenced? where/by whom was the reference published? how many sources are referenced? can the references be checked for their interpretation? y Valid recommendations o Example: are the recommendations clearly grounded in evidence? Assisting Patients/Clients in Using Information and Communication Technologies in Managing Their Health Widespread access to the internet via computers, tablets, smart phones, and other technologies has changed how people access health information. Although there is potential for increased capacity to self-manage health issues, from the common cold to chronic health conditions, there is also a potential increased risk for unintentional self-harm due to poor quality or inappropriate application of health information retrieved via the internet (Kuhns, 2009). The degree to which people are able to retrieve, understand, and apply basic health information and resources is called health literacy (Nielsen-Bohlman, 2004; Canadian Public Health Association, 2006). While literacy, or the ability to read written information, is a component of health literacy, the concept of health literacy is broader and includes the ability to use information and resources in all formats to inform health. Health literacy in Canada is considered low. The results of a Canadian survey conducted in 2007 indicate that 60% of the adult population were health illiterate, and that low health literacy was associated with low levels of education and age, and varied by province/territory of residence (Murray, Rudd, Kirsch, & Grenier, 2007). The results of a recent survey of 103 hospitalized adults in Vermont support the Canadian findings that 60% of adults have low health literacy, and poor vision was the most commonly identified reason given for low literacy (Morris, Grant, Repp, MacLean, & Littenberg, 2011). These results are important considerations for nurses educating patients/clients in accessing good quality health information and present an opportunity in which information and communication technologies can be used to promote patient/ client health (Canadian Public Health Association, 2006). Nurses can act to increase patient/client awareness of the available resources and teach them skills to use the internet to improve their health (Ball et al., 2011). RNAO s Mobile Technology and Client Education highlights critical information for health care professionals in utilizing online resources for client-centered learning. Available at: There are multiple resources available on the internet that can be used to promote patient/client health. These include: y Preventative and disease-oriented health information y Social support, both informally through various forms of social media and formally through organized online support groups (e.g. Social Anxiety Support Community) y Health management tools (e.g. online blood glucose logs) y Health forums where people can post and answer health questions (Saba & McComick, 2006) A variety of online tools exist to help people assess the quality of a website by guiding them through a step-by-step process. Depending on their level of health literacy, people may be directed to one of these online tools where they can learn how to evaluate a website on their own, be taught a series of steps to evaluate a website s quality (see criteria listed above), or be directed straight to a specific trustworthy website (e.g. Health Canada). Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 19

20 Section 2: Information and Knowledge Management Some additional points to consider when teaching patients/clients how to access good quality health information include: y Accessibility and comfort with use of the internet, and information and communication technologies y Literacy y Culture y Language y Physical barriers (e.g. vision or hearing issues) y Cognitive status (Saba & McComick, 2006) Nursing Data and the Advancement of Nursing Practice Collecting patient data is not a novel concept in nursing, however collection of nursingspecific data that is documented electronically is not yet common. In Canada, the focus on pharmaceuticals and diagnostics desired by physicians has meant that nursing-specific standardized data collection has not received as much financial support. Thus, the outcomes of nursing actions remain invisible to nurses and other actors in electronic records and consequently the value of completing the collection and documentation is often lost on nurses (Hannah, 2009). Various initiatives (discussed in the section below) have emerged to create and encourage standardized data collection and use of clinical terms that are nursing-specific. At all levels, including education, it is key to communicate the benefits of data collection for the advancement of nursing. The data collected in practice can inform future nursing practice it is practice-based evidence. Documenting patient data relevant to professional nursing practice has the potential to create various positive outcomes: y allows for trending of patient/client data and the identification of potential problems y provides essential patient/client information during transitions in care (Canadian Nurses Association, 2012) y facilitates the inclusion of nursing actions and outcomes in EHRs y provides a wealth of data to support the development of nursing clinical practice guidelines y provides data on time requirements to perform various nursing activities which can be used to organize nursing care y provides information to decision makers (managers, executives, etc.) on the functionality and effectiveness of their unit y provides information to policy makers on the effects of nursing activities on patient outcomes (Hannah et al., 2009) y increases visibility of the contribution of nurses in patient/client care Students need to learn to be aware of the inconsistencies in the collection and use of data in nursing. Some care facilities do not use electronic health records. Other facilities that do collect data and use electronic records are not necessarily using one of the standardized terminologies (see section below for further information on this topic) The Current State of Standardized Clinical Terminologies In the previous key learning, the importance of data collection to the advancement of the nursing profession was discussed. This section focuses on standardized clinical terminologies, what they are and why they are important to nursing and health care. The purpose of using standardized clinical terminologies is to facilitate the collection of uniform clinical data that 20 Nursing Informatics Teaching Toolkit

21 Section 2: Information and Knowledge Management can be shared among health-care providers and aggregated to inform clinical practice, policy and research. Standardized terms are clear, often shorthand statements of a client concern, a nursing action, or an outcome measure. Standardized terminologies fall into two categories: 1) interface terminologies and 2) reference terminologies (Sewell and Thede, 2013). Interface terminologies permit the clinician to document the concern, diagnosis, action or outcome in discipline-specific format. Reference terminologies work to receive the information sent into the record by professionals in all disciplines and serve to accept and cross-reference terms so that information accepted into the record can be understood within and across disciplines and across various interface terminologies used. Currently, there is no consistent methodology to support uniform clinical documentation through the use of standardized clinical terminology in Canada. This dilemma is not uniquely Canadian. There are numerous standardized clinical terminologies in use in nursing across the globe, some are designed primarily to address the needs of a specific clinical context. Examples include the Omaha Home Health Care System and the Perioperative Nursing Data Set. The lack of standardization among these terminologies presents a significant challenge to the meaningful exchange and comparison of nursing data International Classification for Nursing Practice (ICNP) The task of trying to standardize nursing language has been attempted by many groups, some who addressed only specialty areas, some who addressed nursing diagnosis only, and others who only addressed interventions or outcomes. The International Classification of Nursing Practice (ICNP) was developed by the International Council of Nurses (ICN). ICNP is defined as a classification system comprised of nursing phenomena (diagnoses), nursing actions (interventions), and nursing outcomes that may be used to describe nursing practice. ICNP provides a unifying framework that allows for the cross-mapping of other nursing classifications and terminology languages. ICNP enables the sharing and comparison of nursing data within and across health-care organizations and geographical locations (ICN, 2010; Ball et al., 2011). ICNP terms can be linked in an electronic record so that one can track the statement of a nursing concern (nursing diagnosis) with the nursing interventions applied and the expected and actual outcomes of nursing care. Use of the ICNP in an electronic record system requires two conditions: 1) an electronic To access an FAQ about the International Classification for Nursing Practice, click here: international-classification-for-nursingpractice-icnpr/ record system that accepts the coded terms of the ICNP and 2) use of a care planning tool within the record that permits the nurse to record assessment data resulting a statement of nursing concerns (as in a nursing diagnostic statement) with the care planning elements of stated interventions to address the nursing concern and expected and actual outcomes of the care (ICN, 2010). As a truly unified language system, the ICNP can function as both an interface terminology and as a reference terminology. Use as an interface terminology is described above where the nurse uses the ICNP to document nursing assessment and care. As a reference terminology, the ICNP has ability to accept terms from other nursing language systems and, as described in the section below, some other nursing language systems are currently being mapped to the ICNP for clarity and ease of use. Supporting the Integration of the CASN Nursing Informatics Competencies into Nursing Curricula 21